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Children eligible for free or reduced school lunches may be eligible for Summer Pandemic EBT (P-EBT). Summer P-EBT is a food assistance program administered by the United States Department of Agriculture (USDA) Food & Nutrition Service through the North Dakota Department of Public Instruction and the Supplemental Nutrition Assistance Program (SNAP). The Program provides food assistance benefits to households with school-age children eligible for free or reduced-price school meals during the summer when they don't have access to meals at school.

The benefit is $120 per eligible school-aged child. Benefits are issued via an electronic benefit transmission card (EBT card). Each applicant household will receive one EBT card loaded with P-EBT benefits for all eligible children listed on the application. Households currently receiving SNAP benefits will receive a new P-EBT card with benefits for eligible children.

Children that were enrolled and attending a K-12 school that participates in the National School Lunch program at the end of the school year and were eligible for free or reduced-price meals at school are eligible for Summer P-EBT. All households with eligible children must complete this application to receive Summer P-EBT. Complete the application to the best of your knowledge. Make sure the mailing address is correct.

If your children are not currently eligible but might be for the 2023-2024 school year, you are encouraged to complete this application, and then contact the school where your children will attend next year to complete a Free/Reduced-Price application by August 25, 2023.

Only one application can be submitted for each child. If more than one application is received for a child, benefits will be sent to the household listed as the primary parent/guardian with the child's school. Be sure to read and sign at the bottom of this application.

Questions can be directed to snap-pebt@nd.gov OR call (701)328-2732.

Summer PEBT Application

Head of Household (Parent/Guardian of children)

P-EBT Application ID

First Name

Middle Initial

Last Name

Email Address

Date of Birth

Phone #

Current Household Mailing Address

Address Line 1

Address Line 2

City

State

ZIP Code

Household Address as Reported to School (if different from above)

Address

City

State

ZIP Code

SNAP Benefits Information

Do you currently receive SNAP benefits?

NoYes - Specify state from which benefits are received:

Case Number

Benefits received from

List the School-Age Children For Which You Are Applying

Child 1 First Name

Child 1 Middle Initial

Child 1 Last Name

Date of Birth

Grade

School Name

Relationship to Student 1

Child 2 First Name

Child 2 Middle Initial

Child 2 Last Name

Date of Birth

Grade

School Name 2

Relationship to Student 2

Child 3 First Name

Child 3 Middle Initial

Child 3 Last Name

Date of Birth

Grade

School Name 3

Relationship to Student 3

Child 4 First Name

Child 4 Middle Initial

Child 4 Last Name

Date of Birth

Grade

School Name 4

Relationship to Student 4

Child 5 First Name

Child 5 Middle Initial

Child 5 Last Name

Date of Birth

Grade

School Name 5

Relationship to Student 5

Child 6 First Name

Child 6 Middle Initial

Child 6 Last Name

Date of Birth

Grade

School Name 6

Relationship to Student 6

Child 7 First Name

Child 7 Middle Initial

Child 7 Last Name

Date of Birth

Grade

School Name 7

Relationship to Student 7

Child 8 First Name

Child 8 Middle Initial

Child 8 Last Name

Date of Birth

Grade

School Name 8

Relationship to Student 8

Read and Sign this Application

USDA Non-Discrimination Statement: North Dakota will continue to comply with civil rights requirements, to include providing equal access to individuals with disability and individuals who are limited English proficient.

To file a program complaint of discrimination, complete the USDA Program Discrimination Complaint Form (AD-307) found online at: http://www.ascr.usda.gov/complaint_filing_cust.thms, or at any USDA office, or write a letter addressed to USDA and provide in the letter all of the information requested in the form. To request a copy of the complaint form, call (866) 632-9992. Submit your completed form or letter to USDA by mail at U.S. Department of Agriculture, Office of Assistant Secretary for Civil Rights, 1400 Independence Ave S.W., Washington, DC 20250-9410, by fax (202) 690-7442 or email at program.intake@usda.gov

Penalty Warning: If your household participates in SNAP, it must follow the rules listed below. Any member of your household who intentionally does not follow these rules can be barred from SNAP for 12 months, 24 months or permanently, and may be fined or imprisoned, or both.

Do not give false information, or hide information, to receive or continue to receive SNAP.
Do not give, trade, or sell SNAP benefit to anyone not authorized to use them.
Do not alter any authorization document to receive SNAP benefits you are not entitled to receive.
Do not use SNAP benefits to purchase ineligible items, such as alcohol or tobacco.
*Do not use someone else's SNAP benefits for your household.

I understand the questions on this application. I know it is against the law to obtain or attempt to obtain benefits for which I am/we are not entitled to receive. Any false claim, statement or concealment of any material fact, in whole or in part, may subject me to criminal and/or civil prosecution. As a result of the temporary closure of schools due to the COVID-19 pandemic, the children listed on this application are not receiving free or reduced meals at their school. I certify, under penalty of perjury that the information I have given is correct and complete to the best of my knowledge. I also authorize the release of any information necessary to determine the correctness of my certification. I understand that if I disagree with any action taken on my case, I have the right to request a fair hearing either orally or in writing.

Signature

Submitted On

PANDEMIC FOOD ASSISTANCE FOR SCHOOL-AGED CHILDREN P-EBT APPLICATION

Summer PEBT Application

Head of Household (Parent/Guardian of children)

Current Household Mailing Address

Household Address as Reported to School (if different from above)

SNAP Benefits Information

List the School-Age Children For Which You Are Applying